by Bob Fitzgerald, MD
It’s the middle of a typical hellacious Saturday night shift and your next patient is a 90-year-old gentleman who lives at home with his wife and who fell walking to the bathroom. He has a large scalp laceration, is pleasantly demented, but is becoming more agitated and combative. His wife is “too frail” to come to the ED and the only history you have is a bag with 14 pill bottles in it. Your social worker is long gone, you’re two hours behind on seeing patients, and you look at the full tracking screen and note three more octogenarians with the same chief complaint: weak and dizzy. You soldier on . . .
I work in Sun City, Arizona, where over half my patients are over 70 years. I tell colleagues around the country that I work in “The ED of the Future.” Every shift, I see firsthand the complexities and difficulties of this patient population. Quite frankly, I could not get through a shift without the support of our ED social worker, clinical pharmacist and MLP’s and the outpatient care options available here.
THE AGING OF THE POPULATION78 million baby boomers will become eligible for Medicare starting in 2011 at the rate of 10,000/day. This will undoubtedly create a huge increase in healthcare demand. ED’s will play a pivotal role because they are the critical interface between outpatient services and inpatient care and have a significant effect on resource utilization.
For emergency medicine to be prepared for this essential role, we must:
(1) Recognize the magnitude of the impact of geriatrics on our practices;
(2) Understand the medical and financial imperatives to change our paradigm of care;
(3) Create a new model of geriatric ED practice.
IMPACT OF GERIATRICSIn 2000, 38 million Americans were over age 65. By 2030, this figure will grow to 75 million elderly, with the fastest growth in the “oldest old” (>75 years), who will require more services just when the numbers of doctors choosing primary care are falling dramatically.
Managing the elderly in the outpatient setting is problematic at best because of the limitations imposed by cognition, mobility, transportation, and the limited availability of subspecialists. Hospital-based EDs, with their “one-stop shopping,” become an attractive alternative, especially with abrupt changes in clinical status. And, of course, on weekends, holidays and after hours, we are always the venue of choice. Geriatric ED utilization rates have already been rising – from 12% to 16% of all ED visits from 1993-2003 – a trend which will undoubtedly increase in the future. Conservative estimates see geriatrics as 25% of all ED visits by 2025, and many believe that 30% is closer to the truth.
CHANGING THE PARADIGM OF CAREThe present model of ED care is designed to best serve acutely ill and injured patients requiring rapid interventions and treatments. This paradigm is ill-suited for the typical geriatric patient who has multiple co-morbidities and medications and presents with enigmatic complaints that evolve over a long period of time. There are both medical and financial imperatives to change our model.
Compared with younger severity-matched cohorts, geriatric patients have poorer clinical outcomes. A lack of geriatric-specific training and clinical exposure coupled with limited research and evidence-based protocols compounded by atypical presentations often lead to delayed/missed diagnoses (AMI, sepsis, appendicitis), unsuspected diagnoses (delirium, depression, elder abuse, polypharmacy), undertreatment (PCI in AMI, inadequate pain management) and overtreatment (frequent bladder catheterization, overuse of sedative/hypnotics).
Most importantly, geriatric patients demand the one thing we are least able to give: TIME. Especially in a busy ED, our present model limits our ability to accurately understand their medical needs because of the pressures to move patients through the system quickly. As one nurse colleague succinctly summarized, “It takes me 20 minutes just to undress them, get an accurate med list and a clean UA.”
The financial imperatives of tightening Medicare reimbursements will dramatically affect ED practices in the near future. Falling revenues will further strain physician-patient ratios and limit availability of subspecialists to support our practices. But the financial impact will extend far beyond the walls of the ED. Because we are the biggest Medicare admitters (57% nationally), the consequences of our clinical decisions go directly to the hospital’s bottom line. Twenty-three of the 25 most common DRG’s have a negative cost recovery, and most studies indicate hospitals lose between 15-20% on each Medicare patient. Unfortunately, the future doesn’t look much brighter. The Budget Reconciliation Act of 2005 mandates total reimbursement limits regardless of demand. Following these guidelines, the 2009 Federal Budget proposal includes a $15 billion reduction in hospital payments over the next five years. President Obama has publicly stated he will make controlling Medicare costs a “central part” of his deficit reduction plan. And the scope and related demands and costs of a possible new national healthcare system, also an Obama priority, remain a complete unknown.
What will be the effect of these financial realities on our geriatric EM practices? There will be increasing pressures for EDs to act as more stringent gatekeepers for Medicare admissions – especially for those with vague medical complaints. The era of low thresholds for admissions will be a thing of the past. EDs will be expected to do more extensive evaluations, observe patients longer, seek more consultations, and explore outpatient alternatives. In this new gatekeeper role, EDs will become de facto observation units to prevent avoidable hospitalizations. Clinically, I feel this is the right approach. Hospitals can be dangerous places for elderly patients who do not absolutely need inpatient care.
A NEW MODEL FOR ED GERIATRIC CAREThere has to be a man-on-the-moon-this-decade urgency to change the paradigm of geriatric emergency medicine that will require commitment and a great deal of focused effort. We must begin the process by defining the key elements of this new model: infrastructure, integration and an implementation strategy.
Infrastructure: The foundation of improvement rests on the dual pillars of education and clinical research. Until recently, there has been a deficit of geriatric-specific training in EM residencies. Fortunately, both ACEP and SAEM have been developing elements of a core curriculum to address this. Once developed, this core of knowledge needs to be disseminated to front line caregivers in much the same way as with pediatric and trauma standards of care. The second pillar of clinical research should include special emphasis on risk stratification, prevention, disposition, and outcomes and should include the community hospital setting. These two pillars should lead to at least three useful tools:
(1) Clinical protocols for acute ED care;
(2) Clinical pathways for more definitive treatment in both inpatient and outpatient settings; and
(3) Quality measures to assess our clinical practice.
Integration: Emergency physicians will need to use these pathways to guide the patient seamlessly through the system to the most appropriate clinical setting which may include a period of observation before disposition. On the inpatient side, the ED course should complement and expedite hospital care to minimize length of stay and maximize outcomes. On the outpatient side, the ED should be closely linked with all available resources pertinent to discharge, including the ability to communicate data on our care to those responsible for follow-up.
Implementation: Changes need to be made in ED staffing and design to operationalize this focused geriatric care. Since these patients demand more time and attention than the typical doc-nurse-tech model can give, a geriatric team concept needs to be developed that would ideally include a social worker/case manager and a midlevel provider, supplemented by a clinical pharmacist, OT/PT, pastoral care, etc., as needed. As is the case today, acute medical issues would be addressed by the core ED staff. The rest of the team will be needed to gather all relevant clinical information, address important but non-acute medical issues, explore all disposition options, and screen for other conditions that may affect outcomes.
New design concepts are needed to support this new model of care beginning with the recognition that previous bed number estimates should be revised to reflect increasing lengths of stay. Adjacencies for diagnostic studies and treatments need to be incorporated into overall hospital design as well as accommodations for increasing numbers of caregivers and consultants. Observation areas, either in the hospital or the ED, will be necessary to allow appropriate evaluations. Making our practices more geriatric friendly means addressing the bright, loud, chaotic, cold, uncomfortable environments seen in most departments today by providing quiet, private rooms with softer lighting schemes and pressure-resistant mattresses in close proximity to caregivers with adequate space for in-room visitors and family.
In twenty years most EDs will look like Sun City, at least to some extent. We need to be prepared to provide the best geriatric acute care without placing our hospitals in financial jeopardy.
Bob Fitzgerald, MD, has practiced emergency medicine for 33 years, 16 of which were spent as an ED Director.